Your Name and/or Name of Partner (if working with one):

____________Kelsi Swetland__
____________
______

University of Minnesota - Department of Food Science & Nutrition

FScN 4665 - Medical Nutrition Therapy II - Spring 2015
Case 1
100 Points
Due Date: WEDNESDAY, February 18th
Please be sure to do the following:
Show all calculations, and explain your rationale. Calculations do not have to be typed.
Answer all questions directly on this form. Type all answers (except calculations). Submit in
hard copy in class on the due date. You will be deducted one point per day after the due date
until the hard copy is turned in.
You may work ALONE or with ONE other person. Do not share your work with other
individuals beyond your group. If you work with a partner, you should hand in only ONE
case with your name and your partners name clearly listed at the top of the first page.
Some resources needed for solving the Case:
1. Krauses Food and the Nutrition Care Process, 13th edition. Chapter 31: Medical Nutrition
Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin.
2. Lecture notes and supplemental readings posted under the class topic Diabetes Mellitus in
the Moodle site
3. The following note sets are from MNT-1. These are posted in the Moodle under Reference
Materials and Resources for Cases Selected FSCN 4665 MNT I Course Materials for
your Reference:
a. Nutrition Assessment I-History and Physical Examination
b. Nutrition Assessment II- Anthropometrics
c. Nutrition Assessment III-Biochemical/Laboratory
d. Module I: The Nutrition Care Process
e. Module II: Nutrition Assessment and Monitoring Energy, Protein, and Fluid Needs
f. Module III: Exchange Lists
4. Academy of Nutrition and Dietetics: Evidence Analysis Library Nutrition Guidelines on
Diabetes Mellitus. Link to EAL website is posted in Moodle
5. Standards of Medical Care in Diabetes 2015. Diabetes Care. 38(1) January 2015. S1 S93.
6. Nutrition Therapy Recommendations for the Management of Adults with Diabetes. Diabetes
Care. 37(1) January 2014. S120 S143.
7. IDNT Manual

The case of Mr. Lee Thao

Mr. Thao is a 70 year-old gentleman who is 54 tall and weighs 188 lbs. Mr. Thao is a firstgenerational Hmong American who first came to the US from Laos back in 1975. His past medical
history includes Type 2 diabetes mellitus diagnosed in 1990. Mr. Thaos daughter PaShoua brought
him to the emergency room because he had become disoriented and confused while watching
television. According to PaShoua, her father had a funny feeling before coming to the ER. He had
complained of fatigue, frequent urination, excessive thirst, and hunger over the past couple of days.
Upon admission, Mr. Thao complains of dizziness, nausea, intense thirst, and a headache. The ER
physician observed that he was confused, had tachycardia, and was breathing with difficulty. Urine
tests were positive for glycosuria, but ketones were not present. His blood glucose was 845 mg/dL.
Upon admission he had a temp of 98.6oF, BP of 105/60 mm Hg, HR of 105 bpm, and RR of 20 bpm.
In addition, Mr. Thaos eyes appeared sunken, mucous membranes were dry, and skin was dry and
flushed with poor turgor. He was transferred to the medical intensive care unit and treated with IV
isotonic saline to expand extracellular fluid volume and IV insulin to correct his hyperglycemia.
Potassium chloride and potassium phosphate were added to the IV fluids because urinary excretion
of glucose had resulted in polyuria, causing a deficit of potassium and intracellular shifts were
anticipated with insulin administration. Note: Typically in practice, potassium is frequently added to
maintenance IV fluids, but additional electrolytes (Mg, K, P) are added as needed outside the
maintenance IV fluids.
Laboratory value
pH
HCO3 (mEq/L)
pCO2 (mm Hg)
Sodium (mEq/L)
Potassium
(mEq/L)
Chloride (mEq/L)
Phosphate (mg/dL)
BUN (mg/dL)
Cr (mg/dL)
Glucose (mg/dL)
HbA1C (%)

1/26 1/27 1/28 Normal

7.29 7.35
7.35-7.45
22
24
24-29
28
35-45
135 139 140 136-145
3.2 3.4 3.9
3.5-5.0
108
2.3
32
1.3
845
10.2

104
2.9
27
1.2
240

100
3.2
24
1.0
120

95-107
3.0 - 4.5
8-25
0.6 1.3
70-110
4.8-7.8

ASSESSMENT
Once Mr. Thaos clinical condition has stabilized and metabolic control has been restored, a nutrition
consult is ordered and you prepare to conduct a full nutrition assessment and obtain a dietary history.
From the nurse you find out that Mr. Thao prefers to have his daughter present with the health care
professional and has assigned his daughter to be the primary decision maker for his care. Further,
Mr. Thao only speaks Hmong and his daughter helps with interpretation.
As you answer the following questions, refer to the link Cultural Competence for Clinicians posted
in the Moodle site under Professional Development. Keep in mind that we may have some
generalized understanding about other cultures, which may not be true. So it is important that before
you meet any patient, you recognize individual differences and are careful to not participate in any
stereotyping.
1. As you are approaching Mr. Thao for the first time, how would you address him as you enter
his room? (3 points)
I would enter the room and use the patients formal name, Mr. Thao, and
then ask if it is preferable to call the patient by this name, or for his and
his daughters preference. I would introduce myself to both Mr. Thao and
his daughter, and then ask or confirm that I should also consult his
daughter during the visit.

2. List 3 specific questions you would ask to gain an understanding and help familiarize yourself
about Mr. Thaos cultural background. Explain why you chose to ask these questions. (5
points)
1. Do you use any traditional health remedies to improve your health?
This question is important because we need to know of any treatments
or procedures the patient is using to address his state of health so that
we can work with them and incorporate them into a treatment plan.
2. Please describe your usual diet. Also, is there any time of the year for
which your diet changes for religious or other holidays?
This question is important because the patients usual diet is indicative
of his insulin, or other medication needs, as well as providing
explanation for biochemical lab values (such as blood glucose), physical
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symptoms (such as fatigue or confusion), and anthropometric data (such

as weight).
3. What is your preferred method of treating or dealing with your
diabetes?
This question is important so that the dietitian can understand the
patients understanding of diabetes treatment. It is important to know
this information so that the dietitian can know where the patient is at
and where they need to be directed, in terms of education and
counseling. This question will also help reveal the patients attitude
towards his current health condition and diagnosis, which will provide
insight as to how the health care professional should address the
situation with the patient.

3. Comment on the importance of cultural sensitivity and using proper etiquette while
communicating with patients, explaining why attitudes such as empathy, patience, and respect
are paramount in this situation. (5 points)
Cultural sensitivity and proper etiquette are especially important when
communicating with patients in order to build rapport, trust, and
favorable impressions. Patients are more likely to listen to, and trust,
health professionals that exemplify willingness to understand, and work
with, the individuals personal beliefs and customs. It is important to be
empathetic, patient and respectful in order to accomplish this trusting
and favorable relationship with the patient.

INTAKE DOMAIN
PaShoua reports that prior to admission, Mr. Thaos appetite was good but he was not following a
specific meal plan to manage his diabetes. She is unsure if he has experienced any weight changes in
the past month. PaShoua further stated that despite her encouragement, her father has quit checking
his blood glucose at home and often skips his insulin. When asked about physical activity, she
reported that Mr. Thao is mostly sedentary and spends most of the day at home watching television.
Dietary Intake Assessment
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4. From Mr. Thaos typical dietary intake, determine what each food counts as, in terms of
exchanges. Please count carbohydrate that is designated as such under Other Carbohydrate or
Combination lists as simply Carbohydrate rather than Starch. For this question, you must
use Appendix 34 in the back of the Krause text (pp. 1110-1121); Module III on Exchange Lists;
and the handout on Hmong Foods (for carbohydrate exchanges specific to certain Hmong
cultural foods) posted in the Moodle under Case-1.
Step 1: Determine what each food counts as, in terms of exchanges. Please count carbohydrate
that is designated as such under Other Carbohydrate or Combination lists as simply
Carbohydrate rather than Starch, and then count these separately under Other
Carbohydrates in the table for Step 2. Complete the table below. (15 points)
Breakfast
4 rice patties, baked (each 4" across)
2 Tbsp molasses
2 cups orange juice
1 small banana (4 oz)
Lunch
3 cups cooked rice (glutinous)
3 oz pork (shoulder roast)
large potato (baked with skin) (6 oz)
1 Tbsp butter (stick)
1 cup collard greens (cooked)
16 oz. Diet Mountain Dew
Dinner
2 cups cooked rice (glutinous)
2 oz. cooked ground beef
12 oz. whole milk
1 small mango (count as fruit exchange)
Evening (HS) Snack
3 cups regular microwave popcorn (with butter)
8 oz Diet Mountain Dew

Counts As (Specify Exchanges)

4 starches
2 Other Carbohydrates
4 Fruits
1 Fruit
9 starches
3 medium-fat meats
2 Starch
3 fats
2 non-starchy vegetables
Free food
6 starches
2 medium-fat meats
1.5 whole milk
2 fruit
1 Starch + 1 fat
Free food

Step 2: Add the totals from the table in step 1. Count all items that were listed anywhere besides
the STARCH list, that counted as carbohydrate exchanges, under the Other carbohydrate section
in the table below. Count as starches ONLY those foods listed specifically on the STARCH list. (15
points)

Total
servings/
day

Exchange Group

CHO
(g)

Protein
(g)
15

Starch

22

Non-Starchy Vegetables

Fruit

Other Carbohydrates

Fat-Free Milk

Low-Fat Milk (1/2 - 1%)

Reduced-Fat Milk (2%)

330

66
5

10

High Fat Meats/Substitutes

0
4

0
7

35

25

CHO
(g)

Protein
(g)

Fat

0
0

Fats

12

Total
servings/
day

12

Exchange Group

18

12

12

Medium Fat Meats/Substitutes

12

12

Lean Meats/Substitutes

30

15

1.5

105

Use 0

15

Whole Milk

Fat
(g)

(g)
8

0
0

20

TOTAL grams

493

117

57

Determine kcals by multiplying TOTAL grams

X4=

X4=

X9=

TOTAL KCALS

1972

468

513

GRAND TOTAL KCALS (CHO + protein + fat)

2,953

Step 3: Determine the % kcals provided by CHO. (3 points)

1972 calories CHO / 2953 total calories = 0.6677 * 100 = 67%

Step 4: Determine the % kcals provided by protein. (3 points)

468 calories protein / 2953 total calories. = 0.158 * 100 = 16%
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Step 5: Determine the % kcals provided by fat. (3 points)

513 calories Fat / 2953 total calories = 0.174 * 100 = 17%

Anthropometric Data
5.
A. Calculate Mr. Thaos ideal weight using the Hamwi equation. Then, calculate the % ideal
weight that he is at his current weight. (4 points)
106 lbs. + (4 * 6) = 130 lbs. ideal weight
188 lbs. / 130 lbs. = 144% of ideal weight

B. Calculate Mr. Thaos BMI. Into which category does he fall, based upon the National
Institutes of Health, National Heart, Lung, and Blood Institutes Clinical Guidelines on the
Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, which was
provided in the Nutrition Assessment II: Anthropometry notes? (4 points)
64 inches * 2.54 cm = 162.54 cm
188 lbs. * 0.454 kg = 85.35 kg
85.35 kg / (1.63 m)2 = 32.08 BMI
Mr. Thao falls into the obese category according to the guidelines.

Understanding the Disease and Pathophysiology

6. Explain at least THREE of Mr. Thaos current symptoms and physical examination findings that are
consistent with type 2 diabetes mellitus with hyperosmolar hyperglycemic nonketotic syndrome
(HHNK). Give the physiological rationale for each symptom or physical exam finding that you
identify. (8 points)
1. Blood Glucose concentration of 600 2000 mg/dL Mr. Thaos blood
glucose upon admission is 845 mg/dL, within the range for typical
HHNK blood glucose levels. This was likely caused by Mr. Thaos high
intake of calories, specifically calories from carbohydrates including
rice, which is a high-glycemic food.
2. Profound dehydration Mr. Thao is exhibiting signs of dehydration with
sunken appearance of the eyes, dry mucous membranes and skin, and
poor skin turgor. Mr. Thao also has low blood pressure at 105/60 mmHg,
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which is lower than the normal values of 120/70 mmHg, and is

indicative of dehydration.
3. Minimal or no ketosis Upon admission, it was noted that Mr. Thao had
tested positive for glycosuria without ketones present. This result is
consistent with symptoms of HHNK and Type II diabetes because
individuals with Type II diabetes typically have enough insulin output to
prevent production of ketones.

7. Evaluate Mr. Thaos dietary intake, anthropometric, PE/clinical, and biochemical data pertinent to
his condition. When appropriate, compare his data to standard/normal values. Be as thorough and
SPECIFIC as possible, and then clearly identify at least ONE piece of data that is of concern
from a nutritional standpoint within each data category as you begin to prioritize the most
prominent nutrition issues that need to be addressed. EXPLAIN your rationale for each issue
that you mention.
A. Dietary intake data (Refer back to what you found in question #4 and evaluate Mr.
Thaos intake in terms of major nutrients or food groups that appear to be lacking, and
any obvious problems you think he is having with his intake) (4 points):
Mr. Thao is consuming too many calories overall, as evidenced by his
144% current percentage of ideal body weight. This is an issue
because calorie restriction to promote moderate weight loss is part
of the nutritional management for diabetes.
Mr. Thaos macronutrient composition is technically within normal
ranges, although his carbohydrate intake is at the maximum at 65%,
according to the AMDRs. Mr. Thao should consider reducing the
amount of rice or starch that he consumes at each meal-time
because the amount that he ate, 2 and 3 cups, provides an extreme
amount of glucose to enter the bloodstream and causes a spike in
blood-sugar. This is not ideal for those that are taking insulin and
other medications to accommodate a diagnoses of type II diabetes,
where the main goal is to keep blood glucose levels and
carbohydrate intake consistent and level.

Mr. Thao should consider replacing his meat and milk choices with
low-fat options in order to help reduce the amount of total calories
that he consumes daily.

B. Anthropometric data (refer back to your answers in question #5) (4 points):

Over-weight/Obese BMI Class - Mr. Thao is at 144% of his ideal

weight (according to the Hamwi equation) and with a BMI of 32, falls
in the obese class. Mr. Thaos weight is 188 lbs. while it should be
around 130 lbs. according to the Hamwi equation. This is of concern
because being overweight and increased adiposity can worsen
diabetic symptoms by causing an increase in insulin resistance.

C. PE/clinical findings (4 points):

Severe Dehydration - Mr. Thao had a higher than normal
temperature, low blood pressure and high heart-rate upon
admission, as well as dry mucous membranes, dry skin and poor
turgor.

D. Biochemical data (consider his osmolality and hydration status along with other labs
pertinent to HHNK upon admission) (6 points):
Partially compensated metabolic acidosis Mr. Thao has a pH level
indicating acidosis at 7.29. This is considered partially compensated
because both the HCO3 and pCO2 levels are below the normal range.
The low HCO3 level indicated that the lungs are attempting to
compensate for the kidneys by expelling more CO 2.
Hyperglycemia Blood glucose level is 845 mg/dL on day 1, 240
mg/dL on day 2 and 120 mg/dL on day 3. These values are all above
the normal range of 70 110 mg/dL, indicating hyperglycemia.

Dehydration indicated by Mr. Thaos hyponatremia,

hyperchloridemia, and hypophosphatemia. Due to Mr. Thaos
hyperglycemia and polyuria, glucose is being excreted through the
urine and drawing electrolytes out of the cells into the intracellular
space, and some may be excreted through the urine as well.
Elevated A1C levels A1C levels are normally around 5.1%, however,
for individuals with diabetes an A1C reading <7% is desirable, Mr.
Thaos reading is above the desired range at 10.2%. This indicates
high amounts of glucose in the blood, or high amounts of glycated
hemoglobin.
Hyper-osmotic
(135 mEq/L x 2) + (32 mg/dL BUN / 2.8) + (845 mg/dL glucose / 18) =
328 mOsm/kg
Mr. Thao is hyper-osmotic, which is consistent with his dehydration,
causing movement of electrolytes from the intracellular fluid to
intercellular fluid.

NUTRITION DIAGNOSIS
8. Refer to Module I: the Nutrition Care Process, Nutrition Diagnosis and Medical Record
Documentation and your IDNT Reference Manual. Based on what you discovered in earlier
questions, identify Mr. Thaos most prominent nutrition-related problem within any of the
domains (INTAKE, CLINICAL and/or BEHAVIORAL- ENVIRONMENTAL DOMAINS)
using the standard Nutrition Diagnostic Terminology and INCLUDE the CODE # from the
IDNT manual for your diagnosis.
Nutrition Diagnosis: (4 points)
Excessive energy intake Code # 10635

NUTRITION INTERVENTION, MONITORING AND EVALUATION

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9. Now go back to your nutrition diagnoses. Write a complete nutrition diagnostic statement
in PES format (problem, etiology, signs and symptoms), labeling each section (P, E, and
S) appropriately. Identify your long-term goal, an appropriate intervention strategy to address
the problem, and measurable outcomes you will monitor to evaluate the effectiveness of your
intervention. You may want to use Module II, your IDNT manual, and the What is ADIME
document on the course web site under Reference Materials and Resources for Clinical
Cases to help you with this question.
A. PES: (4 points)
Excessive energy intake (P) related to consumption of high-glycemic
carbohydrate and high-fat food choices (E) as evidenced by a total
caloric intake of 2,818 calories, 144% ideal body weight, BMI of 32 in
obese class, and hyperglycemia.

B.

Intervention Step 1: Planning (i.e. jointly establish goals with the patient)
State at least ONE long-term goal that you will establish collaboratively with Mr. Thao.
Remember that the goals should be clear, measureable, achievable, and time-defined. (2
points)
Long-term goal (i.e. over the next several visits, or longer):
Reduce average daily caloric intake to less than or equal to 2450
calories total (a 15% decrease) within the next 4 weeks by reducing
intake of highly concentrated carbohydrate and high-fat food
choices.

C. Intervention Step 2: Implementing (i.e. carrying out and communicating your plan of care
with the patient). State what nutrition-related action(s) you as the RD will take to address
the problem identified in part As PES statement. Be sure that the INTERVENTION will
specifically address the nutrition-related diagnosis and/or its underlying etiology
described in your PES statement. This information will be documented in the Intervention
section of your ADIME chart note. (2 points)
Discuss food choices and importance of dividing caloric intake
throughout the day with proper macronutrient distribution. Nutrition
education and counseling to help patient understand how to reduce
total caloric intake and promote modest weight loss, in turn
improving diabetic state by keeping blood-glucose levels
consistently within the normal range. Encourage patient to keep a

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food record in order to become aware of food choices and help

evaluate caloric intake during future visits.

D.

Measurable Outcome: State what nutrition care indicator you will MONITOR in order
to EVALUATE the progress of the patient resulting from your INTERVENTION described
in part C. Nutrition care indicators are clearly defined markers that can be observed and
measured and are used to quantify the changes that are the result of nutrition care. For
example, food and nutrient intake data, laboratory values, etc. Keep in mind that you may
also identify clinical/laboratory parameters that you will use to establish tolerance and/or
efficacy of a feeding regimen, if that is the intervention you identified for your PES. Be sure
that the nutrition care indicator can be used specifically to evaluate the success of your
nutrition intervention. This information will be documented in the Monitoring/Evaluation
section of your ADIME chart note.(2 points)
Caloric intake - according to food record or 24-hour recall in order to
evaluate if caloric intake is within range or meeting goal of < 2450
calories.
Blood glucose levels monitored to evaluate whether or not patient is
over-consuming carbohydrates and/or total energy intake.

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